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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I'0FOi'1 ICE USE: � 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR -;RUMP PERMIT Permit No. <br /> THIS PERMIT EXPIRES1-YEAR FROM DATE ISSUED Date Issued LQ �J�3 <br /> (Complete -Zn Triplicate) 14.?-i" . <br /> Application is hereby made to the San Joagtain Local Health District for a permit tci construct <br /> and/or install the workfherein described. ',-Phis application is made in compliance with San Joaquin. <br /> County Ordinance No: 1$62 and the Rules and Regulations of the San Joaquin Local Health District. <br /> !9 <br /> JOB ADDRESS/LOCATION 6,22 <br /> 22 A A-ri 7 CENSUS TRACT - <br /> . II . <br /> Owner's Name M 2R_�.� - Phone ."4(.j(,9 4!3 _ <br /> V <br /> Address i <br /> City 9 TiC'A/ <br /> Contractor's Name 1f cU License # 272 3oj_ Phone 'fit 77-1fS_V <br /> - <br /> TYPE OF WORK (Check) : NEW WELL f DEEPEN/ / RECONDITION /—/ DESTRUCTION /? <br /> / i <br /> PUMP INSTALLATION / PUMP REPAIR '/—/—PUMP PUMP REPLACEMENT i7 <br /> Ether /_7 <br /> — <br /> DISTANCE TO' NEAREST: SEPTIC TANK _zo/ SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation /& ­ ­-,:- <br /> Domestic/private <br /> v: " <br /> Domestic/private Drilled Dia. of Well Casing <br /> Domestic/public Driven Gauge of Casing 1 `z_ <br /> Irrigation Gravel Pack Depth of Grout Seal ;-io <br /> Other - Rotary - Type, of Grout- <br /> ;i Other Other Informationie__ <br /> PUMP INSTALLATION: Contractor <br /> � Type of Pump <br /> PUMP REPLACEMENT: /71 State Work Done <br /> PUMP 'tEPAIR: / / State Work Done N _... <br /> ,DFsTRUCTION OF WELL: Well DiameterApproximate Depth <br /> Describe Material and Procedure ` <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I. will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of�.the well and notify them before putting the welkin use. The above <br /> information is true to the best of my knowledge-and belief. <br /> c <br /> SIGNED <br /> ij (DRAW PLOT PLYN ON REVERSE SIDE) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> APPLICATION ACCEPTED. .BY t DATE /Q 1ZA <br /> ADDITIONAL COAftiiIENTS: ' <br /> PHA II GROUT INSPEC I N . PHA TT/F NAL INSPECTIO <br /> INSPECTION BY • 1� DATE INSPECTION BY DATE <br /> CALL�F.OR A 0 INSPECTION PRIOR TO GROUTING AND FINAL INSPEC ON. <br />_. - E H 1426 5°:`731M <br />